Community Health Advocate - Flint

Job description

Accompany Health is on a mission to give patients with complex needs the dignified, high-quality care they deserve but rarely receive. A primary, behavioral, and social care provider, Accompany Health walks alongside patients for their entire care journey, offering at-home and virtual care, as well as 24/7 support. Partnering with innovative payors, Accompany Health is powered by remarkable care teams, elegant technology, and a commitment to evidence-based practice. We build long-term relationships with our patients so they know, without question, that our team is here for them day or night, year after year. We focus on the health outcomes most important to our patients to make it clear that they lead the way. To achieve our mission, we collaborate with community-based organizations, local providers, and health plans. Led by our empathetic care teams, guided by proven care models, and powered by our own technology, we deliver a level of service that our communities rightfully deserve but rarely receive. While our headquarters is in Bethesda, MD, our teams are distributed across the country. If you’re eager to make a tangible difference in people’s lives, to help correct long-standing disparities in health care, join us. **About the role:** At Accompany Health, we’re reimagining primary care for people with complex health and social needs. As a Health Advocate, you serve as the hands, eyes, and ears of our care team—building trust with patients, supporting virtual clinicians, and helping patients advance their care plans. You’ll visit patients in their homes to facilitate video visits, take vitals, complete screenings, deliver test kits, and follow up on care plan items. You’ll collaborate with an interdisciplinary team of physicians, nurses, behavioral health clinicians, and community health workers to help patients live healthier, more connected lives. ### Responsibilities will include: - **Build trusted relationships:** Proactively in engage with patients’ to build trust and provide support to hard to reach and highest needs patients so they stay healthier, longer, at home - **Facilitate virtual visits:** Set up, support, virtually troubleshoot and/or conduct virtual visits with primary care or behavioral health clinicians, ensuring smooth technology use and readiness - **Conduct in-home assessments:** Record vital signs (BP, pulse, weight, O₂ sat) and provide clear and detailed observations on home environment ,functional status and administering screenings (PHQ-9, GAD-7, PCL-5, AUDIT, DAST, CIWA, COWS) - **Support behavioral health visits:** Partner with clinicians during medical and BH visits by collecting vitals and administering screenings (PHQ-9, GAD-7, PCL-5, AUDIT, DAST, CIWA, COWS) - **Navigate social needs and insurance benefits:** Identify and document social needs (food, housing, transportation, safety) and navigate patients through social resources and insurance benefits - **Support care plan adherence:** Reinforce education, coach on medication adherence and healthy behaviors, and track progress toward goals - **Health Coaching:** Support patients with setting goals , tracking behaviors and supporting through barriers that prevent patients from hitting their goals - **Coordinate care logistics:** Follow up on referrals, scheduling appointments, and tests; manage delivery or pickup of home testing kits or devices - **Deliver and support in-home services:** Deliver supplies and equipment following AH internal procedures - **Document and communicate effectively:** Maintain accurate EHR documentation and consistent updates to the care team - **Visit Accompaniment:** Accompany patients to clinical visits for support with preventative screening and gap closures - Performs other duties as assigned ### What makes you a fit for the team: - Eager to collaborate with a mission-driven, compassionate team that’s transforming care for those who need it most - Driven to make a real impact—helping patients close care gaps and avoid unnecessary hospitalizations and stay healthier at home - Thrives in a fast-paced environment and able to adapt and contribute to continuous improvement - Comfortably manages high volumes of work, can multitask, is organized and can adapt quickly as priorities shift - Fluent in technology and excited to incorporate new technology and systems into daily practice - Adaptable and flexible, embracing evolving systems and technology-driven workflow enhancements - Demonstrates strong growth mindset, including the willingness to unlearn prior workflows and embrace new approaches - Exhibits calm even in ambiguous or rapidly changing situations - Passionate about interdisciplinary collaboration with advanced practice clinicians, nurses, behavioral health clinicians, pharmacists, and urgent care providers - Displays trust in the organization’s mission, values, and direction, and contributes positively to a culture of shared purpose ### Desired skills and experience: **Required** - Experience in a patient-facing role (e.g., Medical Assistant, Community Health Worker, Health Coach, EMT) - Comfortable working in patients’ homes and communities independently, including with medically or socially complex populations - Strong interpersonal skills—able to quickly build rapport and communicate clearly with patients and clinicians - Basic clinical and technology proficiency (e.g., vital sign collection, using mobile apps, supporting video calls) Valid unrestricted driver's license and access to an insured vehicle for daily use - The assigned geographic area (subject to change) may include locations requiring variable drive times; however visit and travel times will be scheduled to fit within the standard workday **Preferred** - Medical Assistant (CMA) or Community Health Worker (CHW) certification, or 2+ years experience in a healthcare setting Experience with value-based care, home-based care, or virtual primary care models - Bilingual or multilingual fluency in Spanish or Arabic is a strong plus; additional fluency in other commonly spoken U.S. languages (e.g., Chinese, French, Russian, Tagalog & Vietnamese) are also a plus